Radioiodine Therapy for Thyroid Cancer and Hyperthyroidism in Patients with End-Stage Renal Disease on Hemodialysis

Abstract

Treatment with radioactive iodine ((131)I) may be necessary for thyroid cancer or for hyperthyroidism in patients with end-stage renal disease who require hemodialysis. Because (131)I is cleared mainly by the kidneys in patients with normal renal function, many issues arise in patients who require (131)I treatment but who are on hemodialysis. This paper presents a case report of a patient on dialysis who required treatment with (131)I for thyroid cancer. We describe a mathematical model, which suggests that the treatment dose of (131)I for a patient with thyroid cancer on hemodialysis would be approximately 13%-28% of a typical empiric dose of (131)I for a patient with normal renal function. Also, we present a comprehensive review and discussion of the literature on patients who are receiving hemodialysis who were treated with (131)I for either thyroid cancer or hyperthyroidism. Using a multidisciplinary approach and special precautions, (131)I therapy can be administered safely and effectively for patients with thyroid cancer or hyperthyroidism who are receiving hemodialysis.

Iodine 131 treatment for differentiated thyroid carcinoma in patients with end stage renal failure: dosimetric, radiation safety, and practical considerations

“…[4][5][6][7][8][9][10][11][12][13][19][20][21] Two recent papers deal exclusively with patients on CPD, 14,15 where the situation is similar to people with normal kidneys in the sense that "renal" plasma clearance of radioiodide is continuous, although considerably lower than that of individuals with normal renal function. Patients on CPD will not be further discussed here as they are not relevant to our cases.…”

“…Publications concerning this latter category of patients have recently been reviewed by Holst et al 2005, who tried to highlight the pitfalls of both empirical and dosimetric approaches as well as to explain the differences in the recommendations regarding radioiodine therapy in the published cases with ESRD on haemodialysis. 6 Radioidine-131 treatment for thyroid disease depends on the ability of high energy beta radiation emitted by this radiopharmaceutical 22 to deliver a lethal dose to the thyroid cells which accumulate it. In the case of DTC, these high range particles would hopefully even reach and destroy adjacent cells with neoplastic potential and poor affinity for iodide: 23 expression of the sodium iodide symporter (NIS) in the neoplastic cells varies and hence the ability of such cells to accumulate radioiodine may be variable.…”

“…It is desirable that these patients also have the additional benefit of 131 I treatment after total thyroidectomy; furthermore, recurrences or progression of DTC may also occur in patients already treated for such tumours before developing end stage renal disease (ESRD); these will also require 131 I treatment. [4][5][6] Since thyroid cancer is a relatively uncommon tumour and the well differentiated type (which accounts for about 90% of cases) has a very prolonged course, no prospective randomized trials have ever been possible for optimizing activities and procedures. Most practitioners, relying on the results of cohort studies and their own experience, have developed suitable protocols for treatment of their patients.…”

“…2 However, while treatment with 131 I is fairly straightforward in the otherwise healthy patient, the administration of 131 I to patients with ESRD presents a number of practical and theoretical problems, which are reflected in the cases that have been published so far in the literature. 6 In the normal individual the kidneys are the thyroid's main competitor for clearing iodide from the blood stream. In the case of renal failure, the activity of 131 I to be administered will need adjustment.…”

“…5,6 Furthermore, radiation safety regulations, as well as purely practical problems arising from radiation phobia, may present a further challenge in treating the ESRD 14,15 It is of interest to note that hardly any two of the papers published so far agree with each other as to the procedure to be followed, the optimal 131 I activity to be used, and the best haemodialysis schedule for these patients.…”